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Severe Personality Disorders

Severe Personality Disorders: Psychotherapeutic Strategies

Copyright Date: 1986
Published by: Yale University Press
Pages: 396
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  • Book Info
    Severe Personality Disorders
    Book Description:

    In this important book, one of the world's foremost psychoanalysts provides the clinician with tools to diagnose and treat severe cases of personality disorder, including borderline and narcissistic structures. Dr. Kernberg not only describes techniques he has found useful in clinical practice but also further develops theories formulated in his previous work and critically reviews other recent contributions.

    "A splendid book . . . of great value for anyone involved in psychotherapy with patients suffering from one or another variety of personality disorder, as well as for anyone who is teaching or doing research in this field. . . . An outstandingly fine and valuable book.-Harold F. Searles, M.D.,Journal of Nervous and Mental Disease

    "Kernberg is a synthesizing, creative eclectic on the contemporary psychoanalytic and psychodynamic scene, broadly based in theory and in practice, a powerful intelligence, a prolific writer, and a man of ideas....This is a challenging and provocative book."-Alan A. Stone, M.D.,American Journal of Psychiatry

    "A major work that brings together in one volume a host of clinical insights into people with a variety of severe personality disorders.... Anyone who has attempted to work with patients with severe personality disorders will be rewarding by studying this book." -Robert D. Gillman,Psychoanalytic Quarterly

    eISBN: 978-0-300-15948-6
    Subjects: Education, Psychology

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Preface
    (pp. ix-x)
  4. Acknowledgments
    (pp. xi-xiv)
  5. Part One Diagnostic Considerations

    • CHAPTER 1: Structural Diagnosis
      (pp. 3-26)

      One of the problems plaguing the field of psychiatry has been that of differential diagnosis, especially when the possibility of borderline character pathology exists. Borderline conditions must be differentiated from, on the one hand, the neuroses and neurotic character pathology and, on the other hand, the psychoses, particularly schizophrenia and the major affective disorders.

      Both the descriptive approach to diagnosis, which focuses on symptoms and on observable behavior, and the genetic approach, which emphasizes mental disorder in the patient’s biological relatives, are valuable, especially with major affective disorders and schizophrenia, but, whether used singly or together, neither has proved sufficiently...

    • CHAPTER 2: The Structural Interview
      (pp. 27-51)

      My principal objective in this chapter is to illustrate the clinical usefulness of structural interviewing, particularly in the differential diagnosis of borderline conditions. The detailed clinical descriptions of different patterns emerging during structural interviews should also illustrate the limits of the usefulness of structural interviewing. To put it briefly, the more a clear-cut psychotic or organic syndrome emerges, the more the structural interviewing resembles the traditional mental-status examination. But for patients within the borderline or neurotic spectrum of psychopathology, the advantages of structural interviewing quickly become apparent. The structural interview not only sharpens the differential diagnosis but also reveals information...

    • CHAPTER 3: Differential Diagnosis in Adolescence
      (pp. 52-67)

      In the older literature on identity disturbances in adolescence, identity crises and identity diffusion were not clearly differentiated. Therefore one can still find the question raised whether all adolescents might present some degree of identity diffusion and hence be indistinguishable from later borderline personality organization. I think one can differentiate borderline and nonborderline character pathology quite easily, utilizing the structural approach to diagnosis. The descriptive and psychodynamic characteristics of severe character pathology and borderline conditions in adolescence have been reviewed by Geleerd (1958), Masterson (1967, 1972), Paz (1976), Michael Stone (1980), and Paulina Kernberg (1982).

      In applying structural criteria to...

    • CHAPTER 4: Personality Disorders in Old Age
      (pp. 68-76)

      In her sociological study of old age, Simone de Beauvoir (1972) passionately indicts society for condemning the large majority of the aged to extreme poverty, uncomfortable dwellings, and loneliness, and then spells out the possibilities for old age. These possibilities, in her view, are now granted to only a handful of privileged people. She states:

      There is only one solution if old age is not to be an absurd parody of our former life, and that is to go on pursuing ends that give our existence a meaning—devotion to individuals, to groups or to causes, social, political, intellectual or...

    • CHAPTER 5: Problems in the Classification of Personality Disorders
      (pp. 77-94)

      Classifying personality disorders is problematic for several reasons. One is quantitative: How intense must the disturbance be to warrant calling it a disorder? Another is semantic: A variety of terms—character neuroses, neurotic characters, character disorders, personality trait disturbances, personality pattern disturbances, personality disorders (the term used in theDiagnostic and Statistical Manual-III)—have been applied to the same clinical syndromes. And behind these semantic differences loom important conceptual, clinical, and ideological issues—for example, the wish to eliminate the termpsychoneurosesfrom a classification system, as stated in the introduction to DSM-III. One’s choice of terminology can thus arise...

  6. Part Two Treatment of Borderline Personalities

    • CHAPTER 6: Expressive Psychotherapy
      (pp. 97-111)

      Because major contributors to the study of the psychotherapeutic treatment of borderline conditions gravitate toward a broad definition of borderline personality, the patients they write about might be classified under different headings in DSM-III and by researchers who tend to prefer a narrower definition.

      Rinsley (1980) and Masterson (1976, 1978, 1980), for example, concern themselves primarily with patients who, in my view (see chap. 5), correspond to the infantile personality. Their patients also seem to correspond with Gunderson’s (1977, 1982) concept of borderline personality disorder and with what DSM-III designates the Histrionic Personality Disorder and the Borderline Personality Disorder. Rosenfeld...

    • CHAPTER 7: Transference Management in Expressive Psychotherapy
      (pp. 112-130)

      Perhaps the most striking characteristic of the treatment of patients with borderline personality organization is the premature activation in the transference of very early conflict-laden object relationships in the context of ego states that are dissociated from one another. Why “premature”? It is as if each of these ego states represents a highly developed, regressive transference reaction within which a specific internalized object relationship is activated. This transference is in contrast to the more gradual unfolding of internalized object relationships as regression occurs in the typical neurotic patient.

      The ordinary transference neurosis is characterized by the activation of the patient’s...

    • CHAPTER 8: Expressive Psychotherapy with Adolescents
      (pp. 131-146)

      The therapist’s fundamental tasks during the early evaluation of the adolescent patient and his family include establishing the diagnosis, recommending treatment, and, above all spelling out the arrangements that should make treatment possible. It hardly needs to be stressed that the psychiatrist evaluating an adolescent patient and his family should maintain a technically neutral attitude. He should have total respect for the adolescent as an independent, autonomous person and should approach him without preconceived notions about what would or would not be proper in terms of the patient’s negotiations with his family.

      The therapist should avoid either being judgmental or...

    • CHAPTER 9: Supportive Psychotherapy
      (pp. 147-164)

      In the context of comparing the appropriate application of psychoanalysis, expressive psychoanalytic psychotherapy, and supportive psychoanalytic psychotherapy, I have suggested (1980, p. 200) that “our understanding regarding supportive psychotherapy may have to be reexamined and reformulated in the light of what we now know about severe psychopathology.” In what follows, I undertake that reformulation.

      Some type of supportive psychotherapy, in relatively “pure” form or in combination with expressive psychotherapeutic techniques, has long been a major modality of treatment in the daily practice of psychotherapists. It is therefore surprising to find so few detailed descriptions of the principles and techniques of...

    • CHAPTER 10: Indications and Contraindications for Psychoanalytically Based Treatment Modalities
      (pp. 165-176)

      Having described the distinguishing characteristics of the various types of psychoanalytically based psychotherapies, it might be appropriate to spell out the general indications and contraindications for each, as well as for psychoanalysis proper.

      These criteria cannot be based exclusively on the diagnosis of the predominant personality organization (neurotic vs. borderline) or on that diagnosis together with the predominant constellation of pathological character traits. The practice of allowing external or circumstantial factors—for example, the patient’s financial circumstances, social or geographic factors, the psychotherapist’s personal preferences and skills, or external pressures on the therapist—to determine the choice of treatment is...

  7. Part Three Narcissistic Personalities:: Clinical Theory and Treatment

    • CHAPTER 11: Contemporary Psychoanalytic Approaches to Narcissism
      (pp. 179-196)

      All three major approaches to the study of normal and pathological narcissism in contemporary psychoanalytic thinking stem from Freud’s (1914) paper on narcissism.

      The first approach, relatively unknown in this country and based on the object relations theory of Melanie Klein, is represented by the work of Herbert Rosenfeld. It has its historical roots in Abraham’s (1919) description of narcissistic resistances in the transference, Joan Riviere’s (1936) paper on the negative therapeutic reaction, and Melanie Klein’s (1957) study on envy and gratitude.

      In a series of four highly condensed papers published between 1964 and 1978, Rosenfeld detailed the structural characteristics...

    • CHAPTER 12: Technical Strategies in the Treatment of Narcissistic Personalities
      (pp. 197-209)

      The most important aspect of the psychoanalytic treatment of narcissistic personalities is the systematic analysis of the pathological grandiose self, which presents itself pervasively in the transference.

      What is unique about narcissistic character pathology is that the pathological grandiose self is utilized in the transference precisely to avoid the emergence of the dissociated, repressed, or projected aspects of self and object representations of primitive object relations. The effect of the activation of the grandiose self in the psychoanalytic situation is a basic distance, an emotional unavailability, a subtle but chronic absence of the normal or “real” aspects of a human...

    • CHAPTER 13: Character Analysis
      (pp. 210-226)

      In line with earlier efforts to enrich an ego-psychology approach to psychoanalytic technique with object relations theory (see Kernberg, 1980, chap. 9), my aim here is to integrate my ideas regarding the structural characteristics of severe character pathologies with Fenichel’s (1941) theory of technique. Fenichel’s proposals for metapsychological criteria for interpretation both incorporated and critically revised Wilhelm Reich’s (1933) technical recommendations for analyzing character resistances.

      According to my understanding, unconscious intrapsychic conflicts are not simply conflicts between impulse and defense but are between two opposing units or sets of internalized object relations. Each of these units consists of a self...

    • CHAPTER 14: Self, Ego, Affects, and Drives
      (pp. 227-238)

      A survey of the psychoanalytic literature on theories of the ego and concepts of the self reveals a considerable terminological confusion. That the termsegoandselfare sometimes used interchangeably, sometimes carefully distinguished from each other, and sometimes treated ambiguously probably is due to the way in which Freud used these words, the way Strachey translated them, and the subsequent elaborations others made on them.

      Freud preserved throughout his writings the Germanlch—“I”—for the ego as both a mental structure and psychic agency, and also for the more personal, subjective, experiential self. In other words, Freud never...

  8. Part Four Severe Regressions:: Diagnosis and Treatment

    • CHAPTER 15: Stalemates in Treatment
      (pp. 241-253)

      Many borderline patients do not change significantly over years of treatment despite the efforts of skilled therapists of various orientations. Because of my particular interest in these patients, I have had the opportunity of acting as a consultant in the treatment of many such cases. What follows are some general considerations regarding the issues frequently involved in the patient’s failure to change and some suggestions for managing therapeutic stalemates.

      Negative therapeutic reactions are a major cause of stalemate. However, I think it preferable to discuss these issues in terms of the lack of significant change and to restrict the meaning...

    • CHAPTER 16: Diagnosis and Clinical Management of Patients with Suicide Potential
      (pp. 254-263)

      To evaluate suicide potential during an initial diagnostic study is obviously more difficult than when the therapist is familiar with the patient. The appraisal of suicide risk in patients who are first seen in a diagnostic evaluation should include consideration of the clinical severity of depression, affective disorders superimposed on borderline personality organization, and chronic self-mutilation and suicide as a “way of life.”

      This diagnostic focus includes both the intensity of suicidal ideation and plans for action as well as the extent to which the depression affects behavior, mood, and ideation. The severity of the depression can be gauged by...

    • CHAPTER 17: Countertransference, Transference Regression, and the Incapacity to Depend
      (pp. 264-274)

      The relationship between Countertransference and the psychoanalyst’s personality may be considered according to at least three conceptual dimensions. The first is what I would call a spatial, or “field,” dimension and has to do with what actually is included under the termcountertransference. I think of this field as a series of concentric circles, the inner ones representing the narrow concepts of countertransference, the outer ones representing the broader concepts. The temporal dimension differentiates acute from long-term “permanent” countertransference reactions. A third dimension is represented by the severity of the patient’s illness.

      Countertransferencenarrowly defined, as is prevalent within ego...

    • CHAPTER 18: Clinical Aspects of Severe Superego Pathology
      (pp. 275-289)

      The two dominant prognostic indicators for the psychoanalytic and psychotherapeutic treatment of patients with borderline personality organization and narcissistic personalities are the quality of object relations and the quality of superego functions.

      The quality of object relations refers to the patient’s internal relations with significant others, not simply to the nature of his interpersonal exchanges. If the patient, in spite of his severe psychopathology, is still able to relate to another person in depth, to preserve a lasting, nonexploitive, nonparasitic relationship with a person who is close to him, he is capable of maintaining object relations. In contrast, the patient...

    • CHAPTER 19: Paranoid Regression and Malignant Narcissism
      (pp. 290-312)

      As I have already mentioned (see especially chap. 12), patients with narcissistic personalities who are undergoing resolution of the pathological grandiose self frequently present complications so severe that the treatment may be stalemated or prematurely disrupted. Because the clinical picture is of a condensation of grandiose and sadistic strivings (a reflection of a pathological grandiose self that has been infiltrated with aggression), I call this phenomenonmalignant narcissism. Malignant narcissism becomes manifest in the form of particular distortions in the transference, sometimes from the beginning of treatment, sometimes after a certain degree of regression in the transference has taken place....

  9. Part Five Hospital Treatment

    • CHAPTER 20: Contrasting Philosophies of Hospital Treatment for Severe Psychopathology
      (pp. 315-329)

      During the first half of this century the large state hospitals, housing from hundreds to thousands of patients, had as their essential tasks to protect the community from mental patients and to provide for these patients over a long period of time a supportive environment within which medical treatment could be applied. It was in the small private psychiatric hospitals, housing between 50 or fewer and 300 patients, that the high staff/patient ratio allowed for the development of a new philosophy of hospital treatment based on psychoanalytic principles.

      This new current was expressed through three parallel approaches: the interpersonal, culturalist...

    • CHAPTER 21: The Therapeutic Community Model of Hospital Treatment for Severe Psychopathology
      (pp. 330-342)

      For more than a decade I have been observing the effectiveness and limitations of therapeutic community modalities of treatment. The therapeutic community has transformed the more traditional types of hospital milieu treatment, opened new roads to the inpatient treatment of severe character pathology, and shed new light on the optimal administrative requirements for psychiatric hospitals. Some of these new insights were not only unforeseen but revealed unintended consequences of this treatment modality.

      Whiteley and Gordon (1979, pp. 105–27), after pointing out that the termtherapeutic communityis one of the most misused and misunderstood in modern psychiatry, define it...

    • CHAPTER 22: Long-Term Hospital Treatment of Severe Borderline and Narcissistic Pathology
      (pp. 343-358)

      In treating patients with severe psychopathology, especially those with borderline and narcissistic character pathology, I have found a modification of the therapeutic community model integrated with intensive individual psychotherapy effective. The model I am proposing has in common with other therapeutic community approaches the effort to openly examine the total social system within which patients and staff interact on a unit; recognition of the need to establish a functional, nonauthoritarian administrative structure that truly permits the examination of decision-making processes and of failures in the assumption of responsibility and in task performance by both patients and staff; and the high...

  10. References
    (pp. 359-374)
  11. Index
    (pp. 375-381)